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August 28, 2006

AVPUPosted by Jim Macdonald at 11:11 AM * 104 comments

Shall we talk about Levels of Consciousness? We shall!

One of your main clues about how sick or injured someone might be is their mental status. Altered mental status tells you that Something Big Is Going Wrong. We little emergency workers use mnemonics to help us keep all this stuff straight (because at two in the morning, with freezing rain dripping down your collar, you just might miss a step otherwise).

First stop on the Mnemonic Express is AVPU. That stands for Alert/Verbal/Painful/Unresponsive. All that “alert” means is “looks at you.” Normally, when you walk into the room, someone will look at you; the eyes will track. That’s the A in Alert. V for Verbal means the guy’s eyes open when you talk to him, but drift closed else. P for Painful means that if we do something noxious to the patient (rubbing a kuckle — hard — on the sternum; pinching the big strap muscle under the armpit) that his eyes open, but otherwise not. U for Unresponsive means Elvis has Left the Building. Nothing we do (and we can get really obnoxious if we have to) will get a response from this person.

After level of alertness, we come to Orientation. Orientation is to Person, Place, Time, and Events. Those are in the order that you can remember them. Does the person know his own name? Who you are is the last thing that goes. Does he know where he is? Does he know the time (this can be in general terms), the day? The month? The year? Last is Events, as in “What happened?” How did this guy come to be lying in a ditch at two in the morning with freezing rain falling on him?

There “I was coming back from Pittsburg down 145, doing around 50 mph when I felt the back end start to slide. I jammed on the brakes, and it spun. The back of my car hit a tree, and after that I opened the door and got out. Then I started felling really tired, so I lay down here” is a lot better answer than “I don’t know.”

You abreviate these in this manner: Alert and Oriented is A Ox4. A patient who responds to Painful stimuli and only knows his name is P Ox1. The patient I talked about in the hyperthermia post was A Ox2: Looked at us as we walked up, knew who she was and where she was, didn’t know what the day (or the season) was, or what she’d been doing that day that led her to be sitting in her garden surrounded by EMTs. Unresponsive is just U. U folks aren’t oriented at all — they just lie there and won’t talk to you. On a scale from Good to Bad, this is over on the Bad side.

(The joke version of AVPU is Alert, Vomiting, Puking, Upchucking. That’s a lot more … well, welcome to EMS.)

Okay, so now you know the Levels of Consciousness (abbreviated LOC). (This is the first part of the Glasgow Coma Scale, of which I may write more later. Level of Consciousness is also the last step of Rapid Triage: Ask the patient his/her name and what happened. If the patient does not reply or answers inappropriately, Red Tag.

Now we get to the fun stuff: figuring out why a person might have an altered LOC. If you know why, you might have a shot at fixing what’s wrong. There is (as you might have suspected) a mnemonic for that. It’s AEIOU-TIPS.

Taking it from the top: A stands for Alcohol. This is pretty obvious: Alcohol will alter someone’s mental status; that’s what it’s for. (If you go to an automobile wreck after midnight and you don’t find a drunk, keep looking: You haven’t located all of your patients yet.)

E is Epilepsy (or any seizure-disorder). A person who’s just had a grand mal seizure will have an altered level of consciousness. Also under E: Environment. Too hot or too cold can make people goofy.

I is Insulin. A person who’s having a diabetic problem may have an altered mental status. Either too much or too little sugar in the bloodstream will slow you down.

O is Overdose. This can be fun drugs; your heroin or ecstasy. Or it can be your prescribed drugs (Granny takes her meds, forgets that she took ‘em, and takes ‘em again), or your accidental poisonings (Junior gets into Mommy’s purse and eats an entire bottle of Flintstones Vitamins). One of the more interesting ones I remember was a guy whose significant other was planning to kill herself with an overdose of pills. Thinking fast, he grabbed the pills right out of her hand and — didn’t throw them down the sink or out the door. He swallowed them himself. (Alcohol was also involved.) Or there was the guy who had a headache, so he took a couple of his dad’s Lasix tablets. This didn’t help his headache (which you wouldn’t expect anyway — Lasix is a diuretic) so he took a couple more. Then more after that. Then the whole bottle. He was pretty dehydrated when we got to him. And he had an altered mental status.

When you think about Overdose, think also about Underdose. Granny forgets to take her pills at all. Or, when the money runs out, folks can’t afford to refill their prescriptions. That happens more often than I like to think.

Think about drug interactions while you’re thinking about Overdose/Underdose. A guy who took nitroglycerine after taking Viagra will have a way altered mental status.

U is for Uremia. This is, essentially, Pee on the Brain. The kidneys aren’t functioning, toxins build up, bad things happen to Mental Status. (The hyperthermic lady I mentioned above had uremia — when the nice nurses at the hospital put a catheter into her bladder the urine return looked like thin molasses.)

On to TIPS:

T is for Trauma. Someone hits you upside the head, your mental status can really change, really fast. Or, someone hits you upside the head and you get a slow bleed, your mental status can change three days from now. We keep asking “Did you fall? Did you hit your head? Did you get knocked out, even for a second?” For that matter, someone who’s bleeding out from a severed artery — that person’s mental status is going to change and not in a good way. With internal injuries someone can bleed out entirely into his abdominal and pelvic cavities without a drop of blood showing on the outside. Hypothermia fits here. Granny breaks her hip and lies on the floor all night — the reason she may not remember might be because she’s cold.

I is for Infection. A high fever will change someone’s mental status, as will the assorted toxins that are floating around in the bloodstream. Watch for UTI (Urinary Tract Infections) in little old ladies. If you can’t figure out what else is going on, think about infections.

P is Psychiatric. Not a lot we can do about this in the field. But mental illness can manifest as altered level of consciousness.

Last comes S for Stroke. A blood clot in one of the arteries in the brain can cause a person to be less than A Ox4. As can a bleed in the brain. Neither one is conducive to long life and good health. S can also stand for Space-Occupying Lesion: a tumor. Something organic is going on with the brain. The signs and symptoms will depend on how big it is and exactly where it’s located.

Bottom line: any time someone around you is showing signs or symptoms of altered level of consciousness and it isn’t just bedtime, consider calling the nice EMTs. Altered mental status can be the very first sign that something serious is wrong.

When you're twenty miles out in the country, it sure does. That's where I run. We have a saying: "If you're in Norton, Vermont, and you have chest pain, you'd better hope that it's indigestion."

On the floor, on his side, is what's called "recovery position." You use that if you're worried the patient might vomit. Another thing to consider for an unresponsive patient while you're waiting for the ambulance is the shock position: on his back, wrapped in a blanket (under as well as over), with his feet elevated.

This whole process of evaluation gets even more fun when you're doing it in the wilderness. (Wilderness is officially defined as 2 or more hours from a medical facility.) I took the Wilderness First Responder class, which is one down from EMT, and even imagining being in that sort of situation was difficult. Our surprisingly realistic simulations were quite stressful, and those weren't even real patients.

Also, when you talk about AVUP as much as you have to for those classes, you come up with all sorts of jokes.

These are excellent posts - thank you. As someone going into the medical field sideways (a dread bioethicist), they're great shorthands and catch-me-ups; have you thought of doing a small book of all this? (Or, I suppose, if there's a great small book already written...)

I'm working on getting all my Red Cross certifications up to speed again, but that'll take a while, since I have to do it around my class schedule.

Question: can being altered ever be a function simply of stress, especially in the elderly? I volunteer in an ER, and I once saw an elderly patient with a dislocated hip who couldn't remember for ten seconds where she was or what had happened to her . . . but once they popped the hip back into place, she was fine, and she went home that night.

Yeah... as the caregiver for an 87 year old diabetic who has frequent TIA's (transient ischemic attacks -- basically small strokes) I deal with this a lot. It's been interesting, learning how to differentiate a TIA from low blood sugar and both from high blood sugar, especially when the person won't or can't talk to you. Oh, and then there's the UTI effect -- as Jim mentioned above. Thank God for glucose monitors.

Yep. I'm (for my sins) Wilderness EMT. (There are people standing in their kitchens this morning in our coverage area who fall under the definition of Wilderness, and wilderness protocols are a Whole 'Nother Barrel of Fun.)

The person with the dislocated hip who recovered to normal mental status after it was relocated is an example of T for Trauma. Pain can really distract someone from minor details like "What day is it?"

Jim, my son has autism. Reading over your examples of Alertness and Orientation, I could see where his responses might be misleading regarding his condition. If he were shaken from an accident, he might not be able to look at or talk to EMTs at all.

Is his autism something EMTs would likely recognize or is this a case where a medic alert bracelet would be useful?

Bottom line: any time someone around you is showing signs or symptoms of altered level of consciousness and it isn’t just bedtime, consider calling the nice EMTs. Altered mental status can be the very first sign that something serious is wrong.

I wish to heck some of my darling classmates would figure this one out. I'm on a dry campus, but the school has pretty much an "Every tolerance" policy when it comes to alcohol. If you're caught with it, you have to write a letter of apology and promise not to do it again (even if you've done it many times before).

And yet for some reason, some people still have the following stunningly intelligent response to alcohol poisoning: "Oh ****, he's uconscious and turning kinda blue! Quick, hide him in his room so the RA doesn't bust him!"

It got a kid killed three years back when his friends mistook a ruptured spleen for AP. College students? Not precisely the brightest bulbs on the porch sometimes.

Re medic alert devices: Any time someone has a significant medical condition, allowing aid workers to discover that without questioning the patient or running tests is a positive thing. If there's a downside, I don't know what it might be.

If someone's not normally responsive after an accident, knowing that the person is autistic (deaf, mute, etcetera) won't cause anyone to rule out neurological damage, but it will help set the baseline.

No one has just one problem. You have trauma plus alcohol. Infection plus hyperglycemia. Stroke plus overdose. It's lots of fun.

Would a medic alert bracelet be useful? Yes. (Note: if it's so worn that no one can read what it says, it's less useful.) Before I do much else I'm checking your neck, both wrists, and both ankles for a pulse (to see exactly how bad off you are). We will find the medic alert necklace or bracelet. If you're allergic to iodine and I find you lying unconscious in the street with a big honking gash on your forehead -- I want to know about that before I start pouring iodine on you from a five-gallon bottle. Similarly, if your baseline is altered mental status, I want to know about that.

But in the case of a motor vehicle collision -- I don't care what your medic alert bracelet says. If you're acting altered, I'm going to assume that you've got a brain bleed going on, not that you're always that way. I'll put you on a backboard, collared, get an IV started, and ship you off to someone with a nice MRI to tell if there's a bleed going on.

One time I went to a traffic accident where the vehicle was a vanload of special needs kids. The only person seriously hurt was the driver, who was therefore unable to tell me what the baselines for the kids were and couldn't help sort them all out and reassure them and such. Things got -- tense -- there for a minute. I was pretty sure the kids were okay, and this was just their baseline. But how to be sure? In a case like that I'd rather over-treat than under-treat, so we treated them all as if they had head trauma.

(Note: None of them were, in fact, injured. Seatbelts save lives. Use them.)

I just want to say that the Making Light posts on emergency medicine fall right into my "most forwarded webpages" queue. I think they're fascinating. Though I am not an EMT or a frequent customer of Emergency Medicine, I can't help a fascination to what I would do under stress, in a pressure situation, and these posts call that kind of crisis up vividly.

I should add, "... without making me feel all alt.tasteless voyeuristic."

Your EMT posts have saved at least one person who was in a bad situation from much worse. My mother's best friend called me one morning to tell me that my mom wasn't making sense, but she wouldn't let the friend call the paramedics, because she (my mom) was really ok. I told my mom's best friend to hang up the phone and call 911 and lie to my mom and tell her that she was just calling for a pizza or some such.

The paramedics found that my mom, who had no previous history of diabetes, had a temp of 104 and a blood glucose of 383.

Remember, EMS is FUN!
I sorta miss that adreneline rush from being woken at 2 am to slog out in the pouring rain and scrape some drunk off the highway, pour him into the back of the rig, listen to his insults and haul him off to the hospital, where a nice police officer would wait for him to be in one piece again.

LOL. Almost as much as I miss the smell of the ones that are already expired on arrival. Ick.

I've got some stories that would make people's hair curl. Motorcycle accident- hey! let's play 'Name that internal organ!'

Lauren, congratulations on your absolutely corrrect advice to your mother's friend. It must have been very frightening for you.

I know this has been said in others of Jim's EMT posts, but I'm going to say it again here -- trauma and disease affect the way you think. When you don't feel well you have the tendency to (and almost certainly will) make (some) very stupid decisions. I am thinking of my own recent experience, in which I chose to drive a car while I was having a heart attack. Nothing bad happened -- but it was dumb.

Take a little old lady. She's got diarrhea. She had it yesterday, she had it last evening, she was still having it at midnight ... now it's three in the morning, the diarrhea hasn't stopped, she's tired of it, and she calls the ambulance.

Those are little old ladies at three in the morning with diarrhea that just won't quit. (Did you ever wonder how I became such an expert at spelling 'diarrhea'?)

Now that can be life-threatening -- dehydration, electrolyte imbalance, plus whatever the cause of the diarrhea might be (Food poisoning? An infection? Something worse?) but it's not a fun call. For anyone.

Well, in my only experience with EMS I managed to make the EMTs laugh:

I had just checked in to my hotel, and after finding my room I was going out to get some drinks and munchies. I didn't see the section of missing pavement and tripped in the trench, whacking my forehead on the nearby trash receptacle. (Warning, Chicago trash cans are mean.)

I sat down on the sidewalk, two teenagers came to my aid. One dashed into the nearby restaurant and came back with napkins, the second whipped out her cellphone and called 911.

Squad arrives, EMTs get me into it, and I announce my name, the day of the week and date, and name the current President, finishing with: "...and I don't think I have a concussion."

The EMTs broke up, then concurred with me, and off to the ER we went.

Five stitches and one tetnus shot later, I caught a cab back to the hotel, immensely relieved that I didn't get an antibiotic as well. (When I questioned this, the nurse explained that head wounds are damn near self-cleaning.)

Jim, my fiance, a former EMT-CC who used to run with a squad up your way-- Upper Valley Ambulance-- and then with one in Central New York, used to call calls like those LOL FDGB (Little Old Lady Fall Down Go Boom). He got a lot of them, especially in the winter in Central New York, and nine tens out of ten they weren't serious. (The tenth time, of course, it's a broken hip.)

Anyway, it's always an experience reading your posts, Jim, and it always reminds me of the fiance's time as a first responder-- he doesn't do it anymore, except for a little bit of ski patrolling, but he ALWAYS pulls over for disabled vehicles or other catastrophes we see while driving.

Uncle Jim, you're pretty lucky (or un, if you're like the EMTs around here who get all sad when there's no one to save). My dad's a Firefighter/Rescuer, and he practically can't leave the house without running into someone who needs help.

It's practically garanteed: Goes out to the supermarket for milk? Finds someone with trouble breathing. Driving me to school? SUV flipped in the median. Road trip to a religious conference? Car-fire on the way down, brush fire once we get there, minor concussion a day or so after that. Either he's cursed or he's a blessing, but either way, none of us ever want to hit him up for rides.

Annalee, it's a strange effect, isn't it? After spending 10 years in software QA, I couldn't use any software without finding a couple of bugs in it...I mean just trying to use it, the bugs would come up and stop me. Fortunately that effect seems to be fading now.

Now that can be life-threatening -- dehydration, electrolyte imbalance, plus whatever the cause of the diarrhea might be (Food poisoning? An infection? Something worse?) but it's not a fun call. For anyone.

Possible side-effect: blot clots. Followed by (if unlucky) system shutdown.

"Jim, my son has autism. Reading over your examples of Alertness and Orientation, I could see where his responses might be misleading regarding his condition. If he were shaken from an accident, he might not be able to look at or talk to EMTs at all.

Is his autism something EMTs would likely recognize or is this a case where a medic alert bracelet would be useful?"

'Round here, we have WHALE stickers for the cars. WHALE stands for We Have A Little Emergency. The one goes on the window, to indicate you have a WHALE sticker. The big one goes on the carseat somewhere, and gives all the child's pertinent information. Then when EMS sees the window sticker he can look for the other one.

Especially helpful if parents are knocked out in a car crash.

Call your local Paramedic joint and see if they have them. I forget what agency gave them to us.

This thread has inspired me to get bracelets for Adam & David. Adam's is easy - diabetes, allergies to seafood and iodine. Not sure what exactly to put on David's, though. "Down Syndrome" isn't useful - it's a syndrome, a set of possible problems, not sufficiently specific. The things the paramedics need to know is that he's a heart patient and that his speech is significantly delayed. (I'm assuming that celiac disease isn't quite as pressing.) I'm not sure how to phrase it, though. He's not "nonverbal" or "preverbal." He just has a limited speaking vocabulary and it takes attention to understand him. He understands a lot more than he can say. Anybody know a terse way of putting that? Those bracelets don't have a lot of space for words.

Christine, if you want we can tell all kinds of stories. You know what's fun? Going to a conference, then going to a diner for lunch, and clearing the room of civilians just by chatting about the job.... I actually edited my last post to about half its length, to take out the stuff that only EMTs would find funny. For example, I deleted the orchiectomy by guardrail, or the neat detail that when someone's nose comes off you can look right down their throats. How about the snowmobiler who had his fingers stuck through a beer can -- in one side and out the other?

Did I mention the time I hurried back from a transfer (cardiac patient to a specialty resource center) in order to drive to Manchester to pick up my son, only to have a motorcycle wreck about fifteen feet in front of me at an intersection? Nice young lady, depressed skull fracture in the center of her forehead (no helmet)... fortunately, EMS response was in about ten seconds (out of my car with my Bag of Tricks in my hand in about that long). Longish story. Happy ending.

All of these should better go in a future post on Trauma: It Isn't Just For Breakfast Any More.

I recommend that everyone take a nice Red Cross First Aid class. You know how people say "A little knowledge is a dangerous thing?" Well, in situations like this, a little knowledge beats no knowledge at all. If all you remember is "direct pressure," you can save someone's life. If you go hiking, take a Wilderness First Aid class. Take the initiative and get a Medical Emergency Response Team set up in your office. Put a Vial of Life in your home.

Ailsa, what you can do is write up a brief history of your child on an index card. If he's in a carseat, tape it to the carseat. If not, put it somewhere else where someone is likely to find it in a crash. Those things that hang off the back of the front seat and hold magazines are good. PUt all the information in a plastic bag, and write "EMERGENCY INFORMATION" on the outside and make sure it's visible.

My mother has more medical conditions than you can shake the proverbial stick at. It has proven very educational. If you or a member of your family has what could be called a complex medical situation, spend some time to preparing.

When you prepare an advance directive, be as specific as possible. Don't put on it "I don't want to be on a feeding tube for an extended period of time." My opinion on what an extended period of time might be vastly different from yours (the patient), and saints forfend if/when any other family members get involved . . .

DNRs as well - make sure that your local EMS folks know you have one, make sure you've registered it at your local hospitals, make sure your family knows, make sure you have a form of it on your person.

Nobody here needs to read my particular take on being prepared for accidents and trauma - I live in interior Alaska, and being twenty miles in the country is urban for us!

(The common name for a person who rides his motorcycle without a helmet is "organ donor.")

Amen.

One of my pet peeves: fellow bicycle riders who won't wear a helmet because it's too costly/hot/uncool/whatever. BS. Yes, it's a matter of personal choice, but a helmet is such cheap insurance, and if you need one (say, because you fall hard enough that *something* around your brain is going to shatter on that rock...), you'll need one *bad*.

However, if all else fails, one can draw comfort from the fact that one can not make a wrong decision about wearing a helmet. If you decide that your brain isn't worth even that tiny bit of effort to protect... you're right. :}

I hate to be stupid, but, whose wallet? Adam's & mine, certainly (and possibly Kathy's as well, just in case), but my main worry is something happening to him on a school outing or something of the sort, or, heaven forbid, something happens to him during one of his escape attempts. He hasn't managed anything serious lately, but the whole deal with sucessful escape attempts is that they happen when you're not expecting them. And we're selling our houes and moving to a completely different part of the state, too, so I really need to have this figured out by then. (He's five, by the way, although developmentally closer to three, and about the size of a small three-year-old.)

Lots of kids with Down Syndrome are escape artists, by the way. We've been looking into GPS transponders (I hope I remembered the right word) as well.

Aren't there companies where you can put their phone number and an ID number on an alert bracelet, and they have a computerized record of what conditions the wearer has?

That may be worth paying for, if your son's situation is that complex. Or put the cell-phone number of someone you know well, and whom you know always has their phone with them.

One advantage with Down's Syndrome is that most people can recognize it by sight, and adjust their expectations. So even if he were to ditch the bracelet and wander off, he's more likely to get appropriate help than someone with a condition that wasn't visually distinguishable.

If he's prone to wandering, writing your phone number in the back of his shirts would probably be helpful. (Inside the collar, out of sight during ordinary wear, but likely to be found relatively quickly.)

Jonquil: Re the Wallet Card, the simplest way would be to write MY MEDICATIONS in red letters on the card, and put it somewhere it would be visible without too much hunting -- either in a clear wallet window, or a credit-card-type pocket with the big red word sticking out. The most important thing is that it gets found -- when they see "Isordil 20mg qid" (or whatever you're taking), the responders will know what it is. If you're worried about wear or dampness, you can pick up laminating sheets at Office Depot or the like.

Critical allergies can also go there.

I tend to have to update my card at least once a year, and I have a Corel file that prints out to a sheet of blank business cards, so I can sow them among my card cases and traveling bags and Elise's purse and so on. If you print that way, you can probably find an image of the hexagonal Emergency Medicine symbol, but it's not really necessary.

My list of meds, diagnoses, allergies, insurance info, doctor info, etc. is large enough that I print them on a sheet of paper -- bright pink sheets of paper -- and print "EMERGENCY INFORMATION other side of this sheet" on the other side. I have one in the car visor (the interior of the car is blue). I have one in the bill section of my wallet. I have one with my meds. I have one in the end table drawer next to the recliner. I have one stuck to the back of the front door.

So far, I've never had to have anybody find them because I've been alert enough to point them out to EMTs. (The local rescue squad always sends two rigs and I tell them I'm large, but I'm not divisible! There's a guy named Mike who can get an IV in the first try without hurting or bruising me, so I'm always happy when he comes. I purposely live a quarter-mile from the rescue squad house and two miles from the hospital. After I come home from the ER, I send the rescue squad a nice letter and a check -- they're volunteer in our city.)

I have been the LOLFDGB. This is my most frequent reason for a trip to the ER. I fall down, I'm pretty sure I know why, I call Kaiser Advice, and they insist I call 911. Everybody assumes I've stroked again when I know it's just that my BP got too low or that I'm having some trouble breathing (and Jim, it *does* get harder to breath in the night) or that I have an ear infection or that I have medication interaction. So far, I've always been right.

As to coma, when I have to explain it to kids, I say it's halfway between sleeping and being dead.

Rescuers sort of have to develop a morbid sense of humor unless they want to go insane. The first life-threatening trauma patient I ever dealt with was in it bad (I've never seen so much blood in my life), and I had no gloves (plus an open cut on my dominant hand), so I was about as useful as a door stop. If the EMTs hadn't cracked a bunch of jokes when they (finally) arrived, I'd have fallen apart.

I frequently tell my CPR/First Aid classes to never have lunch with the EMTs unless you have a strong stomach. The subject comes up because I tell them to make sure that the EMTs are still coming even after a choking situation resolves 'cause EMTs like telling people all the ways they might die from the possible hidden damage (a student of mine told me of someone he knew who had choked on a potato chip. It cleared pretty fast, but boy was his throat sore. Still sore when he went to bed. Next morning, well he didn't have a next morning (swelling can continue to expand for 12 or so hours after the original "insult")).

The new Red Cross curriculum now includes the FAST symptoms for stroke -
Face (can you smile for me) -- do both sides match?,
Arms (raise your arms straight out in front of you like this) --are they approximately level and matched?,
Speech (repeat after me ...) --is it slurred, do they use language as well as they used to, do the do nothing but swear?,
Time -- get a time stamp for when it starts.
I'm real fond of this, it is easy to teach, easy to remember, easy to do.
Now if we can convince the state of Massachusetts to allow us to teach Epinephrine administration and how to help with an inhaler...

Annalee: (44) Yes, morbid sense of humor is a good coping mechanism. It is hard to work effectively when you overempathaize with your patient.(9)Your college needs to get a serious clue (yes, its the students behavior that's the problem but the college's attitude and rules exacerbates the problem). Dry campus? Oh, Society of Friends. You're allowed to make your own mistakes, repeatedly, as long as you're a bit contrite afterwards.(25) Thankfully my "first on scene" superpower is much weaker than that. But it's why I took advanced training in the first place.

Shannon: you can be in "Wilderness Context" in a city on a bad day (think Blizard of '78 or idiots blocking the breakdown lane trying to sneak by the stopped traffic)

Kelly: If you really know your skills cold, you can see if you can challenge the class (walk in, pass the written test, do the skills to a passing mark without coaching). Not all chapters/instructors offer this (maybe because so few people pass). Beware that the standard-of-practice changed this year and you'll have to meet the new standard (google ECC 2005 CPR)

The one time in my life that I really was in a life-threatening situation, about 9 years ago, I was too out of it to realize it. The problem? Blood loss. Not due to an injury, but due to a fibroid in my uterus that was causing uterine bleeding. I had been having "heavy periods" (silly term) for months, and gradually they turned into intermittent heavy bleeding throughout my cycle. On the day in question I'd been bleeding copiously all evening, and I remember talking on the phone to at least one doctor, but for some reason s/he didn't think I needed immediate medical attention. The bleeding had stopped by the time I went to bed, and I set the alarm to wake up at 3 am in case it started again. I remember actually being afraid that I would bleed to death in my sleep, but being too foggy to realize that I could prevent it from happening by going to the hospital. Blood loss can cloud your judgement.

Next morning I went to the urgent care clinic, was told I had severe blood loss, and was given IV fluids (they considered giving me a blood transfusion). I remember looking in a mirror that morning and thinking "wow, I thought 'her lips were blue' was just an expression." At some point during the day I realized that the blood loss had affected my judgement the night before, but it was such a quiet irrationality that my partner didn't realize that I was not thinking clearly and that he should have taken charge. Luckily, no permanent harm was done. Part of the problem in this case is that the situation had developed so gradually -- over a period of months -- that it wasn't clear exactly when it became a crisis.

Annalee, it's a strange effect, isn't it? After spending 10 years in software QA, I couldn't use any software without finding a couple of bugs in it...I mean just trying to use it, the bugs would come up and stop me. Fortunately that effect seems to be fading now.

I'm somewhat notorious for sentences that start with "All I wanted to do was ...". They invariably move on to a medley of annoying bugs and implausible linkages - and almost never finish with " ... and it was easy".

Where do heat exhaustion/heat stroke/dehydration and sleep deprivation fit into your list?

(Only times I have ever been in a seriously altered state, it was sleep deprivation - I have hallucinated, at various times, Ingrid Bergman, floating buildings as in Ringworld, and the Triumphal March from Aida. Fortunately the cure is very simple.)

Jim, when I had concussion in February I knew that I was supposed to try to remember my name before I could remember what it was -- and when I remembered it, I remembered it first in the childhood full name form, though I've had this surname for the last sixteen years.

There's still about half an hour I can't remember, during which I crossed a road, went into a restaurant and ordered a meal.

One of the reasons I don't ride motorcycles is because I've seen what happens when people in cars don't pay attention.

I once had a guy who got hit twice by the same vehicle. Nice man, rapidly going down as we put him in the helecoptor. Or the kid who hit a car in front of him (his fault, don't drink and ride a cycle) and flipped. We couldn't figure out what that lump in his lower abdomen was.

I did go off and Google the new standards; the list of changes is here. http://www.americanheart.org/downloadable/heart/1132621842912Winter2005.pdf I'm going to get recertified at work.

Meanwhile, this: "2. Do not try to open the airway using a jaw thrust for injured victims — use the head tilt–chin lift for all victims."

raises my eyebrows. I'll do what I'm told, and I'll ask the instructor about this one. But surely this one runs the sizable risk of giving the visibly injured patient a free pass to severed-spinal-cord land?

My bad. Didn't finish reading. "Why: It is very difficult to open the airway with a jaw thrust. In addition, all methods of opening the airway can produce movement of an injured spine, so the jaw
thrust may not be any safer than the head tilt–chin lift. The lay rescuer must be able to open the airway for the victim who does not respond. To simplify instruction and ensure that the lay rescuer can open the airway, only the head tilt–chin lift will be taught to lay rescuers."

The choice being between maybe damaging the spine and probably not opening the airway -- well, if you don't get an airway, you lose the patient every time. Another plus: one less thing to remember when the bystander (who may not have had a CPR class in years and has never done it for real) has to think of what to do Right Now.

Oh -- and if the cause of arrest is trauma, the save rates for those is absolutely cruddy anyway.

In a single rescuer situation, I might try a jaw-thrust for the signs-of-life check if I think there is any chance that it is just an airway issue. But I couldn't do single-rescuer CPR without letting go of the head anyway, and we need to get moving on the chest thrusts if they are called for (a lot of the new standard is about stop messing around checking stuff and get going on the move-the-blood-around part, people were going too slow).

The Professional Responder (Health Care Provider) standard still includes jaw thusts, with a person locked on the head fulltime and a real pocket-mask, this is doable (if a little rough on the elbows that are braced on the ground).

Breathing barriers:
You want something between you and the victim (if this stuff works, they are gonna vomit). In classes we use simple flat barriers with a piece of filter-cloth in the middle. Better barriers have a one-way valve. The little barrier I prefer is an MDI Microshield 'cause it has a little tube that goes in the patient's mouth and helps maintain the airway. A pocket mask covers the nose and mouth of the victim and makes a much better seal (and your face is a couple inches away from the patient's).

The microshield is on my hip and the pocket mask in the car (and in my ski patrol belt).

p.s. you know you're overtrained if the first thing you do when you hurt yourself is reack for a pair of gloves.

The one or two times I was altered and attended to by EMTs they twigged to the insulin factor immediately. If only my actual family would get it. I can't tell you how many times I have apparently been unreasonable or acting "bitchy" and had a family member yelling at me for being a jerk (and me just sort of staring dumbly at them while my brain moved in slow motion until it reached the "check blood sugar" task).

A few years ago I drove myself to the hospital while in excruiating pain because of a burst gall bladder. At 12am or so, my addled brain was thinking "don't wake up the husband or kids". Imagine his surprise at being called (once the pain killers were on board) and woken up to be told I was about to have emergency surgery. I also took my knitting with me. You know, priorties and all that...I had to rip the sock I wa working on our a few days later, it had two heels.

I just got back from a cruise to Alaska and had all my meds and medical conditions printed on a highly visible sheet of paper (and had copies stashed hither and thon). It came in useful in Vancouver after the shuttle taking me to the hotel had an accident and sent me flying the length of the bus. And I don't know if it was atypical or not, but I was seen and treated in less than 1.5 hours for a bad sprain (small break) to ankle and related bumps and contusions.

Oh and I carry my 8 year old son's CBC "normals" with me because if he has emergency blood work and no one has been told about his mild Thal. or other hemotological oddities they get kind of panicky.

I appreciate these posts because it's a reminder to basically put things in place to make it easy for EMTs and other proffesionals to access and treat with as much relevant info as possible.

After spending 10 years in software QA, I couldn't use any software without finding a couple of bugs in it...I mean just trying to use it, the bugs would come up and stop me. Fortunately that effect seems to be fading now.
You too? Sadly, although the effect is slowly starting to fade for me, I still make computers cringe just by walking into the room. Most software programmers just refuse to be around me if they're working. (And let's not talk about household appliances, shelving, cupboard doors...)

Of course, now that I've switched fields, I'm finding my new training following me around. Frankly, I think I'd rather be chased by pesky bugs than bioethics issues...

And speaking of! If you live in New York State, please for the love of god, make my job, the job of my colleagues, and every single other medical person practicing in this state easier: go a step beyond living will, and please please please legally dictate your medical proxy. New York State will do everything in its power to keep you alive, if there's no one to legally step in on your behalf, and basically if you don't have the proxy set up, there's no one legally able. This had led to some absolute travesties of medical care being perpetrated!

You can be in "Wilderness Context" in a city on a bad day (think Blizard of '78 or idiots blocking the breakdown lane trying to sneak by the stopped traffic)

That's why I tried to specify "two or more hours," which doesn't say anything about the actual distance. I lived in Ithaca, NY, which is filled with river gorges. If someone falls in the gorge and you need to take them out via stretcher, it could easily take over two hours to get them out of the gorge, much less to the hospital itself. What I think most people don't realize (and what I didn't realize before the class), is that most of the differences between wilderness and regular protocol is how much the layperson is allowed to do. There are a couple of things - among others, resetting a dislocated shoulder - that you are allowed to do in a wilderness setting that there would be no reason to do when you could just bring the person to a hospital.

#65 - I also took my knitting with me. You know, priorties and all that...I had to rip the sock I wa working on our a few days later, it had two heels.

It's probably wrong of me to immediately think in response to this, "How unfair! I can't even manage a single heel yet!"

I had an English teacher once who had worked as a paramedic of some sort for a few years. Her favorite story told to get the high school boys to sit down, shut up, and pay attention was the one about a suicide jumper who'd been covered with a plastic sheet for some hours before she and her coworkers arrived to grab the body. The description of the dried blood sliding off the sheet used the phrase "Cherry Roll-Ups" and the image has remained with me ever since.

We have an EMS Conference up here every year (12-15 October this year).

A perennial topic is "What To Do When the Golden Hour is Shot."

(Note to those not in the trade: The "Golden Hour" is the hour from a trauma to hospital arrival that provides the patient his or her best chance of recovery. The "Platinum Ten Minutes" is the ten minutes you spend on scene -- EMS arrival to ambulance departure with patient on board.)

If you're wearing the Elastomeric Gauntlets of Puissant Fluid Barricado all the time, folks might well take that as odd. But if you put them on in response to a streetcorner crisis, the passersby will doubtless figure that something useful is being done. (Both those who are standing idly by because they Want to See and those who are walking furtively because they Don't Want to be Seen Seeing.)

Mine live in the little keychain case with my CPR mask.

On the other line of defense, on sufficiently cold days, which we get a few of every year up here, I wear a disposable mask both to prevent angina on the street and picking up droplets on the bus. Nobody has ever looked twice at it. (It comes off for building interiors, like the bank.)

Being sleep-deprived to the point of hallucination isn't nearly as much fun as it sounds. Some of the hallucinations can be benign, but they can also be terrifying, and some of them come with full sound-smell-and-touch special effects. Try hallucinating a demon at night, getting up to switch on the light to dispel the nightmare, and feeling it's hand stop yours just short of the lightswitch, while a voice says "Not so fast." (Not mine. Someone I know.)

TNH: absolutely. Even Ingrid Bergman, floating buildings etc are less fun than they sound, because it makes you start to doubt everything else: "well, Ingrid obviously wasn't real. What about the order telling us to recce that building? Was that real? I think I remember being briefed about a Dushka in the upper front window. Was that real?"
Not a good situation to be in.

On sleep deprivation: read "Trawler" by Redmond O'Hanlon for one of the best descriptions I have come across so far.

I'm lucky, my sleep dep hallucinations restrict themselves to "Different Trains" by the Kronos Quartet, but I can be really odd to talk to. The family still hasn't let me live down the grey cake with dragonfly wings or my suggestion that Adam just follow the ladybugs home. And for some reason they think my insistance that he keep the car out of the trees was funny. I still maintain that it's perfectly sensible advice.

In those hallucination situations, would "sleep deprivation" translate into something more like "waking dreams"? Those sound like dreams -- or nightmares -- to me. (There's also that condition of sleep medicine takers who can cook or drive while not really being awake.)

Faren, they're called hypnagogic ("sleep-leading") hallucinations. They happen when you dream while still awake. This is not a normal brain function.

I know someone who's a paranoid schizophrenic. He's OK when he's on his meds, but when he's off them he sleeps 1-2 hours a night for months on end. Pairing the hypnagogics that would result from that with his delusions...well, I'm glad he's staying on his meds.

"If you're wearing the Elastomeric Gauntlets of Puissant Fluid Barricado all the time, folks might well take that as odd. But if you put them on in response to a streetcorner crisis, the passersby will doubtless figure that something useful is being done."

One of the experienced responders in my class said that part of the reason for putting on the gloves even if no obvious fluids were involved was to make it clear that you knew what you were doing -- it calmed everybody involved, including you, down, and introduced a small breathing space.

If any of you ever encounters me acting really vague, tell me to check my blood sugar. Though at this point, I have a reflex single-mindedness: get glucose meter. Check level. Take glucose tablet if too low.

I wear a MedicAlert bracelet. This is the company that gives you a unique ID number, and maintains a data base of all your conditions, medications, and contact phone numbers -- doctors, insurance, next of kin. There's a toll-free number stamped on the bracelet. People like Jim look for it.

Add to beth at #82:
The stainless-steel bracelets they have now are sealed to keep the enamel on the emblem. They'll last about ten years before they're worn enough at the jump-rings to need replacing. (I've gone through three in thirty years. I also have a necklace, which I don't wear unless the bracelet's died.)

From experience: it's an antibiotic, so it isn't something that you'd likely to be given by an EMT. However, if you're allergic to it (and I am), the margin for treatment of the reaction can be so short that little can be done, or so long (more than about ten minutes) that you might be on your way home before it gets bad enough to notice. Both are Not Good.

FWIW, my reaction time is in the 3 to 5 minute range - I can't get out before I fall over unconscious from Not Breathing. I wear my dogtag all the time, and I make sure that allergy is listed on the medical record (fortunately it is a common allergy). It sure makes for a short list of available antibiotics, though. *G*

People with penicillin allergies tend to have reactions to other, similar antibiotics.

While no one is going to give you PCN in the field, it's entirely possible that you might be carted off to the ED somewhere, out of your head with fever, and whacked up with antibiotics because what's wrong with you is infection.

I'd prefer to have any "If you give me this I'll die" information out where folks who might (in an emergency situation) give it to me can see it.

(When doing a history on a patient, the second thing the nice EMT asks you (right after "what's going on?") is "Do you have any allergies?" That really is info you want 'em to have.)

S. Dawson - EMTs (and I hold a similar cert for outdoor emergency care) are worried about getting you to the ER alive. Infection comes later. They don't even carry penicillin.

But nobody gets in contact with your "emergency contacts" to ask about allergies. For one, how will they know who they are? Wear the warning bracelet! If you are not responsive enough to answer the allergy question, the first thing I'll look for is a Med-Alert tag.

Thanks to everyone for your advice and concern. I'm not even 100% sure that I am allergic to penicillin; I broke out in hives once after being given amoxycillin as a small child, and haven't had any -cillins or similar antibiotics since. So on the one hand, I may have outgrown the allergy, but on the other hand, I'm aware that reactions can suddenly go from annoying things like hives to life-threatening things like closing airways and shock. Is this something I ought to have tested? How do they test you for potentially life-threatening allergies, anyway--expose you and then quickly stick you with an epi-pen if you react?

Okay, never mind about the last question, I've looked up the answer. I wonder why no doctor I've ever seen--all of them, obviously, aware of my possible allergy--has ever mentioned that this could be a potential problem in an emergency situation, or advised me to consider testing and/or wearing a bracelet?

Consider one of our cases: A guy found by the side of the road wearing jogging clothes (little nylon shorts, mesh tee-shirt, running shoes), no wallet, no cell phone, no ID. He's hot to the touch, maybe going septic. Decreased level of consciousness, incoherent. No one recognizes him; not from around here.

Being sleep-deprived to the point of hallucination isn't nearly as much fun as it sounds

So I get this EEG about a month ago, when, in a desperate attempt to figure out why I'm so exhausted. Afterwards, the neurologist is completly not beliving that I haven't been living in a world of constant hallucinations, and is forced to use the word "severe" and not "extreme" in the diagnosis, because I won't cop to halluciantions. Yes, I saw Jar Jar explode. But we have video of that.

Note: You *never* want to hear this from a neuro -- "Did you drive? You shouldn't be driving."

Being human again is quite wonderful, thank you. The point of all this? Sleep deprivation kills you in the worst way -- it leaves your body alive.

(For the record, a med I was taking was letting me get all the Stage III sleep I wanted, and more. Stage IV and REM sleep? Not so much. This stands as the most evil side effect ever.)

How fun is being alive? Well, in this midst of laughing and crying at a Dar Williams lyric, I clearly hear on the recording the sound of a Nokia cell phone reporting that it has reached full charge. The laughter doubled. It's good to be back. Well, Disney helped too. Space Mountian. Three times. Erik better.

I may be one of the few to come back from a Worldcon more aware than when I arrived.

Coming to the subject of EMS humor late, I was in an emergency room at the tender age of 20 because my foot was severely swollen. I was parked in a wheelchair, since I didn't need to lie down, and tucked into a corner behind some curtains. On the other side of those curtains I got to listen to one fireman relate the story of a woman found in a burning house. She hadn't burned to death. She had completely baked. The details, as PJ so pithily put it, are not ones I will forget.

Periodically, that thought wanders thru when I bake a roast. Fortunately, I'm not squeemish.

(Heat stroke, perhaps - he's dressed for exercise, and you don't say anything about the weather but it's late summer in the northern hemisphere, and What Was The Last Episode of Uncle Jim's Emergency Medical Theatre, anyway?)

The number two cause of ALOC in the elderly is UTI (urinary tract infection). These are quite common, and can expedite the Cincinatti Stroke Assessment and leave you scratching your head. Also dont forget that a large elderly population do not quite appreciate that fine drug we hand out like candy here, Phenergan. Hypersensitivity to this can make Grandpa not only walk for the first time in 5 years, but throw punches at you like you stole his girlfriend from Pearl Harbor days. As a rule of thumb, if its not cured by a nasal trumpet (NPA), Narcan, or D50, only high flow desiel can cure it in the field. Definately justifies a return with lights and sirens.

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